Provider Demographics
NPI:1134305188
Name:EL DORADO PAIN MANAGEMENT CENTER
Entity Type:Organization
Organization Name:EL DORADO PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:HR
Authorized Official - Phone:530-672-1311
Mailing Address - Street 1:1208 SUNCAST LN
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9631
Mailing Address - Country:US
Mailing Address - Phone:530-672-1311
Mailing Address - Fax:530-672-1335
Practice Address - Street 1:1208 SUNCAST LN
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9631
Practice Address - Country:US
Practice Address - Phone:530-672-1311
Practice Address - Fax:530-672-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-20
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83780208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A837800Medicaid
CA00A837800Medicaid
CA00A837802Medicare PIN